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///2018 Abstract Details
2018 Abstract Details2019-08-02T15:57:01-05:00

Two cases of thrombosis after prophylactic tranexamic acid administration during cesarean-hysterectomy for placenta accreta.

Abstract Number: S1D-2
Abstract Type: Case Report/Case Series

Danielle McCullough MD1 ; Elena Reitman MD2; Ruth Landau MD3; Laurence Ring MD4

Case 1

A 36-year-old G3P1 presented at 22/5 with concerns of PPROM. Examination revealed ruptured membranes, chorioamnionitis and placenta previa/percreta. KCl termination followed by hysterectomy was planned. Prior to cesarean, placement of central venous catheter required multiple attempts in the right internal jugular (IJ) followed by a single attempt in the left IJ. 1 g prophylactic tranexamic acid (TXA) was dosed prior to hysterectomy. Estimated blood loss (EBL) was 2L; the patient was transfused 4u PRBCs, 4u FFP and 250cc cell saver. On post operative day (POD) 2, ultrasound revealed bilateral jugular DVTs. Hematology recommended no intervention. The patient was discharged on POD 4.

Case 2

A 36-year-old G2P1 with suspected placenta percreta presented for elective cesarean-hysterectomy (C-HYST) at 37/4. Rapid infusion catheter required several attempts to place in the left antecubital vein. Cesarean was performed under neuraxial anesthesia with delivery of the placenta, however, hysterectomy was needed due to uterine atony and bladder adhesions. 1 g TXA was dosed prophylactically and general anesthesia induced for hysterectomy. An EBL of 6000ml required transfusion of 10u PRBCs, 10u FFP, 1u platelets and 1u cryoprecipitate. On POD 2 left brachial vein DVT was diagnosed and enoxaparin started.

Discussion

We present two cases of C-HYST with prophylactic TXA, postpartum hemorrhage, significant transfusion and thromboembolic complications. Preoperatively, beyond being pregnant, neither patient had risk factors for thromboembolic events. Difficult line placement was encountered in both patients. The use of tranexamic acid to reduce peripartum hemorrhage has recently garnered considerable attention. TXA has been shown to reduce peripartum blood loss and mortality secondary to hemorrhage without increasing rates of thromboembolic events. However, when attempting to apply these findings to the care of specific patients, the limited quality (non-rigorous blinding, qualitative outcomes measurements, low-resourced settings) of many of these studies must be noted. While we can draw no causal or correlative relationship between the TXA administered and the thrombotic complications in these patients, neither can we dismiss any link.

Conclusion

Although current literature suggests TXA is safe for prevention of hemorrhage-related mortality in the pregnant population, these cases highlight the need for further evaluation of possible risks in obstetric populations and the need for careful assessment and individualization of treatment, perhaps even sparing the use of TXA in certain cases.

1. Lancet 2017; 389(10084): 2105-16.

2. Lancet 2011; 377(9771): 1096-1101.

3. American Journal of Perinatology 2011; 28:233-40.

4. Thrombosis and Haemostasis 1993; 70(2): 238-240.

SOAP 2018